DRAFT

DRAFT

Slide footer on all slides unless otherwise noted

Confidential – for policy development purposes only

Slide 1

MassHealth Payment and Care Delivery Reform: Public Meeting

Executive Office of Health & Human Services

January 13, 2016

WORKING DRAFT - FOR POLICY DEVELOPMENT PURPOSES ONLY

Slide 2

Agenda

  • Recap of overall direction for care delivery & payment reform and timelines
  • Review specific approach for transition to accountable care system
  • Next steps
  • Additional program updates

Slide 3

Key principles and goals for our accountable care strategy

What we plan to do

  • Move to a sensible care delivery and payment structure where:
  • We pay for value, not volume
  • Members drive their care plan
  • Providers are encouraged to partner in new ways across the care continuum to break down existing siloes across physical, BH and LTSS care
  • Community expertise is respected and leveraged
  • Cost growth and avoidable utilization are reduced

Slide 4

Payment and Care Delivery Reform – overall construct

  • MassHealth is exploring linking payment and care delivery reform strategies with Massachusetts’ conversations with CMS about the 1115 waiver
  • State commits to annual targets for performance improvement over 5 years
  • Make case to receive federal investment upfront through waiver
  • Seek upfront CMS investment in new care delivery models
  • Upfront funding at risk for meeting performance targets
  • Creates access to new funding to support transition and system restructuring
  • Access to new funding contingent on providers partnering to better integrate care
  • ACO-like model with greater focus on delivery system integration
  • Total cost of care accountability
  • Key principles
  • Partnerships across the care continuum
  • Explicit goals on reducing avoidable utilization (e.g., avoidable ED visits) and increasing primary, BH, and community-based care;
  • A feasible and financially sustainable transition for provider partnerships that commit to accountable care
  • An appropriate focus on complex care management, e.g. through a Health Homes model
  • Explicit incorporation of social determinants of health, through the technical details of the payment model and in care delivery requirements;
  • Valuing and explicitly incorporating the member experience and outcomes

Slide 5

Current thinking for eligible populations

  • Starting point: Medicaid-only population, including those with LTSS needs, included in MassHealth ACO models
  • MassHealth spend only
  • Non-dual HCBS Waiver populations eligible, ACO budgets will not include waiver services
  • Future discussions on how to bring value-based contracting expectations to SCO/One Care models
  • ACOs will be financially accountable for physical health, BH, and pharmacy (with adjustments for price inflation) starting in year 1
  • We will transition financial accountability for MassHealth state plan LTSS costs over time, starting year 2 to allow for:
  • Establishing strong partnerships between ACOs and LTSS providers
  • Developing solid measurement strategy for quality and member experience
  • Discussions with CMS and approvals
  • ACOs will have broad responsibility to integrate care across all these disciplines and to integrate social services and community supports
  • This is a starting point and we will explore ways to further increase coordination and expand integrated and accountable care to other populations over time, including duals

Slide 6

Timeline

Timeline Subject to refinement based on progress of Work Groups, discussions with CMS, etc.

Goals

  1. Inform the design of new payment and care delivery models

Aug 2015 – Jan/Feb 2016

  • Conceptual discussion
  • Identify options and set direction
  • Targeted testing of major policy options for feedback
  1. Foster dialogue across different parts of the delivery system

Detailed technical design starting in Jan/Feb 2016

  1. Inform MassHealth’s discussion with CMS re: 1115 waiver
  • Will be released for public comment in Q1 of CY2016

Where we are:

  • Productive discussions on several topics
  • Further discussion upcoming on several topics

Slide 7

Agenda

  • Recap of overall direction for care delivery & payment reform and timelines
  • Review specific approach for transition to accountable care system
  • Next steps
  • Additional program updates

Slide 8

Accountable Care: Topics for discussion today

A. CMS Waiver and Federal Investment:

- Goals for cost and quality

- Goals / framework for distribution and use of funds

B. ACO care and payment model, member experience

C. Care coordination, community partnership, health homes

D. Social determinants of health

Slide 9

A. Context on DSRIP Investment Model and CMS Expectations

What is Delivery System Reform Incentive Program (DSRIP)?

  • Waiver program in which providers can receive time-limited federal investment to catalyze delivery system improvement
  • Funding at risk and tied to performance metrics
  • Several states have received significant new federal funding under DSRIP waivers, to catalyze/accelerate care delivery reform or implement new payment models
  • Going forward, significant number of other states “competing” for funding; process will be more structured than states receiving earlier investments (OR, NY)

Expectations from CMS

  • State commitment to concrete and measurable improvement targets on cost, quality, and member experience
  • Implementation of and broad participation in alternative payment models (APMs)
  • Meaningful delivery system reform, including provider partnerships across the care continuum
  • Confidence in state ability to execute successfully

Slide 10

A. CMS Investment and Targets: Concept Overview

MassHealth is currently exploring the possibility of applying for funding from CMS to invest in delivery system reform. The idea or concept is that, the more aggressive Massachusetts’ targets are, the larger the anticipated savings, the larger the potential net investment from the federal government.

In addition, MassHealth intends to agree to specific reductions in costs off of the current trend and calculate the total expected savings over a 10-year period. This expected savings will represent the figure for which we will apply for funding to investment in delivery system reform.

For example, if we apply for $2B in upfront investment over 5 years, we could expect $0.6B in year 1, $0.6B in year 2, $0.3B in year 3, $0.3B in year 4, and $0.2B in year 5.

Investment is explicitly temporary and goes away after year 5.

In subsequent years, reform is self-sustaining and supported by savings.

Slide 11

A. Preliminary view on uses of DSRIP funds

  • ACO start-up costs, subject to accepting minimum level of lives, to implement population health management capabilities
  • Subsidized support for population health management operating costs for a limited transitionary period
  • Investment in integration for BH, LTSS, social and human service providers into new payment models (further discussion in section C)

Slide 12

A. Accountability for quality and access measures: Use of measures and domains

Use of measures

  • 2 different uses for measures:
  • CMS Waiver agreement: The state will be accountable to CMS
  • ACO Payment model: ACOs will be accountable to the state
  • Vetted, national measures with stable baselines for payment / CMS accountability
  • Additional measures for reporting only: Reporting-only measures can transition to accountability after baselining period
  • Potential to include few additional custom measures key priority domains (e.g., LTSS)
  • Need to balance complete system-level measurement with parsimony/alignment to avoid administrative burden
  • Strategy to risk-adjust for patient mix
  • Evolution of measure slate as we gain more experience with ACOs and as measurement science advances

Measurement Domains

  • Member/caregiver experience
  • Access
  • Care coordination / patient safety
  • Preventive health and Wellness
  • Efficiency of care
  • At risk or special populations, as applicable
  • Behavioral Health
  • Chronic conditions
  • LTSS (e.g., frail elders, disabled) Key area of emphasis for quality workgroup
  • Pediatrics
  • Opioid users
  • End of Life

ACOs will be accountable for established quality and utilization measures from Day 1

Slide 13

A. Draft Measure Slate for CMS accountability

Care coordination / Patient safety

•Medication Reconciliation Post-Discharge (MRP)

•Timely transmission of transition record

•Care for Older Adult (COA) - Advanced care plan

Prevention and Wellness

•Well child visits in first 15 months of life (W15)

•Well child visits 3-6 yrs (W34)

•Developmental screening in the first 36 months of life

•Oral Evaluation, Dental Services

•Adolescent well-care visit (AWC)

•Prenatal & postpartum Care (PPC)

•Tobacco use assess and cessation intervention

•Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

•Adult BMI Assessment (ABA)

•Chlamydia Screening in Women (CHL)

Efficiency of care

•Use of imaging studies for Low Back Pain (LBP)

•Hospital All-Cause Readmissions

•Potentially preventable ED visits (NYU ED)

•PC-01 Elective Delivery

End of Life Care

•Proportion admitted to Hospice for less than 3 days

•Hospice and Palliative Care – Pain Assessment

At Risk Populations

•Controlling high blood pressure (CBP)

•PQI-5: COPD

•PQI-8: Congestive Heart Failure Admission Rate

•Medication Management for People with Asthma (MMA)

•Comprehensive diabetes care: A1c poor control (CDC)

•Comprehensive diabetes care: High blood pressure control (CDC)

Behavioral Health / Substance Abuse (Obtaining further input on these measures from workgroups and stakeholders)

•Screening for clinical depression and follow-up plan: Ages 12-17

•Screening for clinical depression and follow-up plan: Age 18+

•Initiation and Engagement of AOD Treatment (IET)

•Follow-Up After Hospitalization for Mental Illness (FUH)

•Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)

•Depression remission at 12 months

•Follow-up care for children prescribed ADHD medication

Long Term Services and Supports(Obtaining further input on these measures from workgroups and stakeholders)

•Patients 18 and older with documentation of a functional outcome assessment and a care plan

•Service/care plans address participants' assessed needs (including health and safety risk factors) either by the provision of waiver services or through other means

•People who make choices about the people who support them (PES)

•People who feel their staff have adequate training (PES)

For measures that do not have an existing baseline, accountability will start in outer years

* Outcome measures

Slide 14

A. Patient experience measures for CMS accountability

Who

  • Patient experience data will be collected based on a joint procurement by MassHealth, HPC, and CHIA
  • This is expected to:
  • Include members MassHealth and Commercial plans
  • Include members with LTSS needs
  • Include pediatric age groups

What

  • Patient experience measures used in commercial/Medicare APM models, e.g.,
  • Getting timely appointments (access)
  • Provider communication with patients (care coordination, patient centeredness)
  • Customization / additional questions to reflect unique needs of the MassHealth population and priorities for MassHealth ACO models, e.g.,
  • health literacy
  • health & functional status, resource stewardship

Slide 15

B. ACOs can achieve member-driven, integrated care

Integrated, accountable care and Payment and accountability

Graphic showing Accountable/Coordinated Care Entity including Integrated Care Team (ICT) with PCP, Provider Type 1 and Provider Type 2 with an option of additional Provider Types, with an emphasis on ACO integration and coordination, forming an Integrated Care Team (ICT).

Elements required for ACOs to have meaningful impact

  • A network of providers who serve as an integrated care team (ICT) for the member
  • Increased member engagement in care
  • Integration and investments into LTSS, BH and social determinants
  • Aligned payment model (global payments)
  • Panel stability to support continuity of care and investments in population health

Slide 16

B. Network of providers who serve as a coordinated care team (CCT) for members

Expectations and Capabilities

Coordinated care team (CCT)

  • Well defined set of providers – can vary, but in all cases must represent PCPs, BH, and expertise in social determinants and LTSS
  • Should be able to direct the majority of care
  • Can represent multiple organizations, but must have clear delineation of roles
  • PCPs (and in some cases BH providers) are the quarterback of care
  • Greatest impact and member benefit if care (handoffs) remain within the CCT where possible – promotes coordination, accountability and efficiency

Policy Implications under Consideration

  • ACOs should have some reasonable ability (varying levers) for keeping care within the CCT
  • Members likewise should be able to opt-in and opt-out of ACOs (and their CCTs)
  • ACOs must clearly communicate CCT providers upfront

Slide 17

B. Coordinated Care team: Example Design Levers for discussion (based on Medicare Next Gen ACO model)

Population-Based Payments

  • Allow ACOs designate a Preferred Provider Network (PPN), a subset of the broader provider network a member has access to (analogous to the CCT concept)
  • ACO gets paid a prospective PMPM and, in return, is paid a reduced FFS rate for care provided by PPN providers to attributed members
  • This gives ACOs up-front access to funds and some flexibility to manage their provider network

Prospective Global Capitation

  • Providers in the PPN do not get paid FFS for caring for members of their ACO
  • Instead, the ACO receives prospective PMPM capitation to cover these costs
  • This gives ACOs even greater up-front access to funds and flexibility to negotiate terms within their care team
  • Requires ACOs to have the infrastructure to manage these contracts, pay claims, and submit encounter data to MassHealth

Slide 18

B. Increased member engagement in care

Principles

  • For an ACO to be successful, members must experience care differently and be more actively engaged in their care
  • Joining an ACO should be a two-way commitment
  • Member understands and agrees to care by the CCT
  • The ACO commits to a more coordinated experience of care through the CCT and clear communications/handoffs across providers and with members

Policy Implications under Consideration

  • Member opt-in or selection of an ACO should occur through a variety of mechanisms, e.g.,:
  • Selection of integrated ACO/MCO product, or
  • Selection of PCP that is part of an ACO, with a clear recognition of ACO responsibilities
  • Member incentives (financial and network-related) to keep care within a CCT, as appropriate

Slide 19

Member engagement: Example Design Levers for discussion

Voluntary Alignment, Enhanced Benefits, and Coordinated Care Payments

  • Features of Medicare Next Gen ACO model
  • Members in the ACO may “voluntarily align” with the ACO, engaging more actively with their care team.
  • ACOs have the ability to offer enhanced benefits (e.g., telehealth services) that are paid for by Medicare to these members
  • Medicare to authorize direct “Coordinated Care Payments” (~$50/year) to reward members who receive most of their care from the PPN care team

Primary Care Referral Authorizations

  • Feature of many managed care constructs, including the PCC Plan (for some services), which empowers the primary care providers to authorize certain services
  • We could expand primary care authorization to include more services, when a provider is outside of the PPN
  • This could increase coordinated care within the PPN while allowing for a “release valve” controlled by the member’s primary care provider

Slide 20

B. DRAFT – MassHealth Accountable Care Models - Framework for discussion

MassHealth’s current thinking is that we will develop four accountable care models. Members will choose which option best suits their needs. Members will also select a primary care provider once they have selected an option.

The options include MCO/ACO and ACO options, B, C and D. The ACO options include PPC, MCO1 and MCO2.

MCO/ACO, Provider

Model A: Prospective ACO/MCO model

  • Fully integrated TCOC model
  • ACO/MCO entity takes on full, two-sided risk

PCC, ACO, Provider

Model B: Direct to ACO model

  • Provider-led, TCOC model
  • Pricing model focused on performance vs. insurance risk

MCO1, ACO, Provider

Model C: Retrospective ACO model

PCMH, Provider (Not eligible for DSRIP funding)

Model D: Patient Centered Medical Home

  • For remaining providers
  • To be further defined, likely a PCMH model

Slide 21

C. Care coordination, community partnership and health homes – approaches under consideration

  • Incorporate an approach to care management for members with complex needs, e.g. through an integrated “health homes” / “community partner” model
  • Emphasize appropriate partnership with certain community organizations with existing expertise
  • Encourage to “buy” and form partnerships rather than “build” new capacity
  • Use DSRIP funds to invest in infrastructure for BH, LTSS, social and human service providers
  • Create the right program structure, requirements and incentives to leverage community-based organizations with expertise in managing socially complex populations as partners in the ACO care model

Slide footer: DRAFT Confidential – Proprietary and predecisional

Slide 22

C. Background: Health Home Services in the Affordable Care Act (ACA)

  • ACA §2703 requires health home programs to include the following six service types:
  • Comprehensive care management
  • Care coordination
  • Health promotion
  • Comprehensive transitional care
  • Individual and family support
  • Referrals to social and community support
  • States have flexibility to define these services
  • Services do not include treatment
  • Services should include use of health information technology, as feasible and appropriate

Slide footer: DRAFT Confidential – Proprietary and predecisional

Slide 23

C. Example funding model

MassHealth’s current thinking is that we will see new federal investment funding through DSRIP and Health Homes mechanisms. We have provided a graphic explaining possible flow of funding to ACOs and Certified Community Partners under MassHealth. The goal is to provide direct funding to both ACOs through DSRIP funding and certified community partners through Health Homes funding, with the understanding that they will develop memoranda of understanding (MOUs) to coordinate and manage patient care.

MassHealth DSRIP Program (DSRIP funds + potentially § 2703 Health Homes funds)